Jaycee Brown

Jaycee Brown

Director of Communications

Benefits Verification — How It Makes or Breaks Your Claim

There are some things you do automatically in your dental practice. Industry traditions that have proven “tried and true” and you wouldn’t imagine not implementing. Appointment confirmations, collecting copays, paperless charting, insurance verification, etc. Think about it – how many patients do you check insurance benefits on so that you can accurately quote and present treatment? The answer is probably more than half. However, for practices billing medical insurance, many of them are not following the same steps which includes verifying benefits. When filing medical claims this can be a costly and time consuming mistake.
The average medical claim is between $2,500 and $10,000. In order to estimate what a portion of that the patient may owe you MUST check benefits. Medical insurances do not automatically cover services at 100% (a common misconception). Benefits are subject to deductibles, out of pocket maximums and exclusions. Proper treatment planning will require knowing these basics of the patient’s policy. The first step is to call the insurance company (use the number on the back of the patient’s insurance card) and ask what the patient’s remaining deductible and out of pocket maximum is. Also have your codes ready, even dental codes are ok or just procedure descriptions, and ask the representative if services are covered and what the percentage of coinsurance is. Using mock data we will demonstrate below how this information helps you estimate a treatment plan.
Let’s imagine you have called on Mrs. Smith’s Cigna benefits and she has a $2,500.00 deductible of which she has only paid $1,350.00, a $5,000.00 out of pocket maximum of which she has only paid $1498.00 and the extraction, bone graft, tissue graft and implant you are wanting to do is covered at 60%. Procedures added up are a total of $9,500.00. The breakdown below shows how we formulate the patient’s portion.
          $9,500.00 – total cost of procedures
          –$1,150.00 – remaining deductible (the deductible must be paid before the plan covers services)
          $8,350.00 – total cost after deductible
         –$3,340.00 – this is the 40% coinsurance of the above remaining total, if this amount were over the $3,502.00 remaining on the out of pocket    
          maximum the patient would only pay up to the $3,502.00.
          $5,010.00 – total anticipated insurance payment
          $4,490.00 – total estimated patient payment ($1,150.00 deductible + $3,340.00
Had you not verified the patient’s medical benefits and gone on the assumption of the medical covering 100% you would now be faced with both collecting several thousand dollars from the patient and explaining to them why you did not estimate correctly when benefits were clear and available.
Imagine any of these procedures had not been a covered benefit. You would then be spending time and money submitting a claim that you could ultimately know in advance would not be paid. Non-covered services are not appealable if there was no good faith to believe it would be covered (an approved preauth, a representative told you it would be covered on a recorded benefits call, the service is listed as covered in the member’s coverage booklet, etc.). Or what if preauthorization was required for any of the services the patient needed? Lack of preauthorization is a valid reason to deny a claim and usually can only be bypassed when treatment is rendered in an emergency room or as a life-saving measure. Many times if preauthorization is necessary but not obtained the insurance company will even go so far as to name the patient as also not being responsible for the charges.
Verification of medical insurance benefits is different but takes no more time than verifying a patient’s dental benefits. In fact, it may take less time as you are checking for much less information. The way to have the most success with your medical claims is to know your patient’s coverage, provide them with as accurate an estimate as possible and have a realistic expectation of payment based on verified data.
Dental Billing Tips and News for Pros; Edition #134


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